Intussusception

Last Updated on by FRCEM Intermediate

Overview

  • Intussusception is the invagination of a proximal segment of bowel into the distal bowel lumen.
  • The commonest occurrence is a segment of ileum moving into the colon through the ileo-caecal valve.
  • Any age but commonly occurs in the 2 month to 2 years (peak 5 to 9 months).

Clinical features

  • Intermittent pain which is colicky, severe and may be associated with the child drawing up the legs.
  • Episodes typically occur 2-3 times/hour and may increase over the next 12-24 hours
  • During these episodes of crying the child may look pale.
  • vomiting is usually a prominent feature, but bile stained vomiting is a late sign
  • Bowel motions
    • Blood and/or mucus
    • Classic red currant jelly stool is a late sign

Examination

  • Abdominal mass – sausage shaped mass RUQ or crossing midline in epigastrium or behind the umbilicus, palpable in about two thirds of children.
  • Distended abdomen
  • Stool: Bloody stool/occult blood positive
  • absence of bowel in the right lower quadrant (Dance’s sign)
  • Signs of an acute bowel obstruction
  • Hypovolaemic shock is a late sign

Investigation

  • Plain abdominal X-ray – to exclude perforation or bowel obstruction
    • visible abdominal mass, abnormal wind pattern, dilated bowel loops, air-fluid level
    • Target sign – 2 concentric circular radiolucent lines usually in the right upper quadrant
    • Crescent sign – a crescent-shaped lucency usually in the left upper quadrant with a soft tissue mass

 

  • Gas insufflation enema (or contrast enema)
    • Diagnostic investigation of choice if high level of suspicion
    • This intervention is both diagnostic and therapeutic
  • Ultrasound scan
    • soft-tissue mass, ‘doughnut sign’, pseudokidney/sandwich appearance, ‘target sign’

  • Routine blood tests
    • Blood glucose
    • Blood group and hold prior to theatre
    • FBE and U&E may be useful if the child looks unwell

Management

  • Analgesia
  • Nil by Mouth
  • Nasogastric tube to decompress the bowel
  • Start IV rehydration
  • Refer to pediatric surgeons

Complications

  • Ischaemia, infarction and necrosis
  • Obstruction
  • Perforation
  • Peritonitis
  • Sepsis
  • Hemorrhage

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